While undergoing a soapsuds enema, the patient complains of abdominal cramping. Which of the following should be the nurse's first action?
a. Immediately stop the infusion.
b. Slow the rate of infusion.
c. Advance the enema tubing 5 to 8 cm.
d. Clamp the tubing.
B
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A If the nurse stops the infusion, the patient will not receive all of the fluid, and the enema will be less effective. The nurse can slow the infusion until the abdominal cramping passes.
B The nurse should slow the rate of infusion if the patient complains of abdominal cramping. Cramping may prevent the patient from retaining all of the fluid, which would alter the effectiveness of the enema.
C The enema tubing should not be advanced farther.
D The tubing may be clamped temporarily if fluid escapes around the rectal tube. However, in the instance of abdominal cramping, the nurse's first action should be to slow the rate of infusion.
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